Provider Demographics
NPI:1174263206
Name:WILSON, HAYLEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:HAYLEY
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IL
Mailing Address - Zip Code:61561-7585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7585
Practice Address - Country:US
Practice Address - Phone:309-923-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily